Invasieve behandeling van hartritmestoornissen

Invasieve behandeling
van hartritmestoornissen
Natasja MS de Groot
cardioloog-electrofysioloog
Erasmus Medisch Centrum, Rotterdam
Invasieve behandeling van hartritmestoornissen
= invasieve behandeling van tachycardieën
Non-Invasieve Behandeling
medicatie
cardioversie
chemisch
electrisch
Mechanisme van tachycardieën
• Abnormale impulse formatie
- enhanced automaticity
- triggered activity
• Abnormale impulse conductie
- circus movement
DAD
EAD
Invasieve behandeling van hartritmestoornissen
catheter ablatie
epicardiale catheter ablatie
endovasculaire catheter ablatie
Veneuze Toegang
v. jugularis
v. cava subclavia
transseptaal
transaortaal
v. cava inferior
epicardiaal
Mapping Techniques
Epicardial
Mapping
Contact
Mapping
NonContact
Mapping
3-D ElectroAnatomische Mapping Technieken
simultaan
sequentieel
Multi-Site
Mapping
Endocardial
Mapping
Manuele Navigatie
Remote Navigatie
robotische navigatie
magnetische navigatie
Nadelen manuele catheter ablatie
 lange procedure tijd
 lange blootstelling aan röntgen straling
 nauwkeurige localisatie catheter tip
 catheter stabiliteit
Remote Catheter Navigation
Magnetisch Navigatie Systeem
Stereotaxis NIOBE®
Robotisch Navigatie Systeem
(Sensei Hansen Medical)
Remote Catheter Navigation
Magnetische Navigatie Systeem
Stereotaxis NIOBE®
Magnetische Navigatie
By courtesy of T. Szili-Torok
˝Floppy˝ Catheter
atraumatisch
Geen curve
Effectief genoeg ?
By courtesy of T. Szili-Torok
Remote Catheter Navigation
Robotische Navigatie Systeem
(Sensei Hansen Medical)
Robotische Arm
Artisan Sheath en Ablatie Catheter
outer sheath
inner sheath
ablation catheter
Working Station (Hansen Medical Inc.)
*
*
* EP system
*
*
*
*
* Fluoroscopic images *Electroanatomical mapping system
Ablation catheter
(Navx)
H
CS
RVA
I
aVF
V1
RV
RA
His
CS
I
aVF
V1
RV
RA
His-D
His-P
CS 9-10
CS 7-8
CS 5-6
CS 4-3
CS 1-2
RV
H
CS-p
CS-d
Adenosine testen
catheter ablatie
van een
atrium flutter
Karakteristieken van flutter golven
1) trage descenderende component
2) snelle negatieve deflectie
3) scherpe upstroke
4) geringe ‘overshoot’
Counterclockwise Atrial Flutter
H1
H2
H3
H4
H5
H6
H7
H8
H9
H10
CL 250 ms
Terminatie van de atrium flutter
245 ms
CS 2-1
CS 4-3
CS 6-5
CS 8-7
CS 10-9
635 ms
A
B
C LLR AFL
D
MA-PV AFL
ULR AFL
IART
3-D Electro-Anatomische Mapping Systeem
M
R
R
M
R
M
M
“early”
R
•
•
•
M
- 100 ms
R
•
“late”
•
M
+ 95 ms
•
Sinus Ritme
60 ms
SCV
-30 ms
His
TV
ICV
Diagnose
Diagnose
220 ms
-203 ms
ICV
Diagnose
catheter ablatie
van een
atrium fibrilleren
Focus als trigger voor AF
Pulmonaal Venen Isolatie
ECG
PVs
PV
isolation
AF
CS
‘Fire’ or ‘ICE’ ?
Cryothermale energie
-80°C
LSPV
LIPV
RSPV
5 minutes/vene
By courtesy of Dr. R. Bhagwandien
RIPV
Radiofrequente Stroom
tio 1). More prominent His
stal
His
bundle
(HB)
catheter
RAO
distal
His
bundle
(HB)
catheter
RAO
on
His
His
Abl
Abl
LAO
LAO
LAO
His
His
Abl
Abl
HisHis
HIS
AblAbl
HIS
HisHis
AC
AblAbl
he
AC
11
11
1111
LAO
LAO
LAO
AC
Abl Abl
V
Atrial
Atrial Fibrillation
Fibrillation
Atrial Fibrillation
Atrial Fibrillation
RAO
RAORAO
or
O]) RAO
RAO
a
undle
dle
AV junctie ablatie
RAO
RAO
or RAO
O])
ation
al
. The
distal
o
w iwthd
raw
n n
soso
t hat
iLAO
t il ti es
across
t he
superi
or or
margi
n of
the
i thd
raw
t hat
l i es
across
t he
superi
margi
n of
the
t ritcuspi
d dannul
usus
(FiLAO
g. g.11-60).
velvel
y, y,t he
catheter
ri cuspi
annul
(Fi
11-60).A lAternati
l ternati
t he
catheter
AC
LAO
LAO
Abl
Abl
HIS
His
His
His His
HIS
A V
A V
AblAbl
AblAbl
HisHis
al
A:V> 1
HisHis
M
M
MM
AV block
RF ablation
V-pace junctional escape
Vragen ?